• RCR IN-HOME RECOVERY MASSAGE & BODYWORK

  • REFLEXOLOGY INTAKE & INFORMED CONSENT

  • This form helps me personalize your reflexology session and identify health or skin concerns that may require changes, postponement, or medical clearance. Please answer completely and honestly. Fields marked * are required.

  • SECTION 1 | CLIENT INFORMATION

  • Date of birth **
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • SECTION 2 | YOUR REFLEXOLOGY GOALS

  • What would you most like from your reflexology session? **
  • Have you received professional reflexology before? **
  • Which area would you like treated? **
  • Preferred pressure **
  • Are your feet or hands especially ticklish or sensitive? **

  • SECTION 3 | CURRENT FOOT, ANKLE & HAND CONCERNS

  • Are you currently experiencing any of the following? **
  • Current discomfort level (0 = none; 10 = worst imaginable) (optional)
  • Have you had foot, ankle, hand, or wrist surgery or a significant injury? **
  • Has a healthcare provider given restrictions concerning your feet, legs, hands, circulation, pressure, or positioning? **

  • SECTION 4 | HEALTH & SAFETY SCREENING

  • Have you been diagnosed with or experienced any of the following? **
  • Are you taking a blood thinner / anticoagulant? **
  • Are you currently pregnant or postpartum? **
  • Active blood clots, contagious illness, open wounds, skin infections, acute gout, significant unexplained swelling, or other health changes may require the session to be modified or postponed. Medical clearance may be requested when appropriate.

  • SECTION 5 | COMFORT & SESSION PREFERENCES

  • Would you like lotion or a topical product used when appropriate? **
  • Would you prefer a fragrance-free session? **
  • Conversation preference **

  • SECTION 6 | IN-HOME APPOINTMENT INFORMATION

  • Are there pets in the home? **
  • Please secure pets away from the treatment area and provide a clean, quiet space with minimal interruptions.

  • SECTION 7 | REFLEXOLOGY INFORMATION & INFORMED CONSENT

  • I understand that reflexology is a complementary wellness practice involving pressure applied to specific areas of the feet and/or hands for relaxation and general well-being.

    I understand that reflexology is not medical diagnosis or treatment and is not a substitute for care from a qualified healthcare provider. No claim is made that working a reflex point will diagnose, cure, prevent, or directly treat a disease or medical condition.

    I have disclosed relevant health conditions, medications, injuries, surgeries, skin concerns, allergies, symptoms, and healthcare restrictions to the best of my knowledge. I agree to report changes that may affect the session.

    I understand that reflexology pressure may feel tender in some areas. I will communicate if pressure or positioning is uncomfortable and may request changes or stop the session at any time.

    I understand that temporary tenderness, fatigue, relaxation, or changes in how I feel may occasionally occur after a session. I will seek appropriate medical care for symptoms that are severe, new, worsening, or concerning.

    I understand that the practitioner may modify, postpone, decline, or discontinue the session because of health, safety, professional-boundary, or environmental concerns, or when medical evaluation or clearance may be advisable.

    By signing below, I voluntarily consent to receive professional reflexology services.

  • SECTION 8 | PROFESSIONAL BOUNDARIES

  • RCR provides professional wellness services only. Appropriate boundaries will be maintained throughout the appointment. Inappropriate comments, requests, exposure, touching of the practitioner, or behavior that compromises safety may result in immediate termination of the session.
  • Date **
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECTION 9 | PRACTITIONER REVIEW - OFFICE USE

  • Follow-up or clarification needed (optional)
  • Items requiring follow-up (optional)
  •  
  • Should be Empty: